Fragmented System for Frequent Hospital Users Presents Challenge

Study finds one out of every four patients visits different hospitals during two-year span

Katherine Hempstead, a senior program officer with Robert Wood Johnson Foundation and former director of health statistics for the state Department of Health and Senior Services.

Many patients in need of carefully coordinated healthcare are instead being treated by a patchwork of providers, which presents a particular challenge when it comes to chronic conditions.

A newly published study by New Jersey researchers found that one in four patients with multiple hospital admissions during a two-year period were admitted to different hospitals. The fragmentation of care was even greater for patients with chronic conditions or who had behavioral health problems.

At a time when there is an increased emphasis on the importance of coordinating health care, particularly for patients with chronic conditions like diabetes and congestive heart failure, the study shows what kind of challenges providers face.

“This is something that really complicates different kinds of care coordination activities,” said Katherine Hempstead, the lead author of the study.

The report, published yesterday in the journal Medical Care, covered patients between the ages of 18 and 64 who had more than one hospital stay over a two-year period, with the first visit occurring in 2007 or 2008.

The heaviest hospital users -- those who had 15 stays over the two years -- had the most fragmented care, with 55 percent visiting at least two hospitals. Other factors that predicted visits to multiple hospitals were if the patients were middle-aged, had private insurance, and lived in an area with several competing hospitals.

Fragmenting care between multiple providers can lead to unnecessary testing and a breakdown in communications between caregivers.

“It was really inefficient and wasteful of resources,” said Hempstead, a senior program officer with the Robert Wood Johnson Foundation and the former director of health statistics for the state Department of Health and Senior Services. She also is a visiting professor at Rutgers University.

“Everyone’s familiar with the idea of getting a second opinion, but this goes way beyond that,” Hempstead said.

There are a several potential strategies that could minimize the negative effects of fragmented care, Hempstead noted. They include changes to private insurance plans so that they're encouraged to visit the same hospital and a greater deployment of health information technology that makes it possible to share patients' electronic records.

Insurance plans must strike a balance between narrow networks -- which limit patients’ choices -- and broad networks that can lead to fragmented care, Hempstead said.

She also indicated that competition can contribute to fragmented care. “There are very complicated issues about how can these institutions work together when they’re still competitors,” said Hempstead

Hempstead noted the timing of the study was a good one, since the Affordable Care Act is now reshaping healthcare. Study results can serve as a “baseline” for future research.

Another strategy that could benefit some of the patients facing fragmented care is the state’s planned Medicaid Accountable Care Organization, which will require participants to share patient information. While it won’t help those patients with private insurance plans, it could help lower-income residents.

The study’s other authors include Joel Cantor, director of the Rutgers Center for State Health Policy and a columnist for NJ Spotlight.

Cantor explained that the state's Medicaid ACOs are intended to change the model of healthcare delivery by rewarding providers for improving the quality of care while decreasing costs. The New Jersey program will include all of the hospitals in a geographic area.

Cantor also said the study points to the challenges facing a population of patients who already are difficult to treat -- those with behavioral health issues.

“Those with behavioral health issues are much more likely to have fragmented care than those without,” Cantor said. “They need the most continuity of care with their providers, because they might have very difficult-to-manage conditions.”

The other authors were Rutgers professor Derek DeLia; University of Southern California's Tuan Nguyen, a former Rutgers researcher; and Dr. Jeffrey Brenner, medical director of Cooper Health System’s Urban Health Institute and the executive director of the Camden Coalition of Healthcare Providers.